Uganda Voucher Plus Activity Quarterly Report Year 4, Quarter 1 October – December 2018

Submission Date: 31 January 2019

Name: Dr. Christine Mugasha

Number: AID-617-LA-16-00001 Activity Start Date and End Date: January 29, 2016 to January 28, 2021

Submitted by: Christine Namayanja, Chief of Party Abt Associates Plot 86 Luthuli Avenue Bugolobi P.O.Box 37443 Kampala Uganda Office: +256 414 223546 | +256 312 305900

Email: [email protected]

Copied to: [email protected]

This document was produced for review by the United States Agency for International Development Uganda Mission (USAID/Uganda). USAID|Uganda Voucher Plus Activity 1 1

Acronyms and Abbreviations ...... iii

Activity Information ...... v

1. Activity Introduction ...... 1 1.1 Activity Description ...... 1 1.2 Performance Analysis to Date ...... 2

2. Activity Implementation Progress ...... 6 2.1 Summary of Implementation Status ...... 6 2.2 Progress Narrative ...... 8

3. Guiding Principles ...... 11 3.1 Partnership, Collaboration, and Stakeholder Engagement ...... 11 3.2 Learning and Adaptation ...... 12 3.3 Inclusive Development ...... 13

4. Leadership and Development ...... 13

5. How has Activity Addressed AOR Feedback from Last QR? ...... 13

6. Summary Financial Management Report ...... 14

7. Management and Administrative Issues ...... 15 7.1 Key Management Issues ...... 15 7.2 Resolved Management Issues...... 16

8. Planned Activities for Next Quarter Including upcoming Events ...... 17

9. Annexes ...... 18 9.1 Activity Work Plan ...... 18 9.2 Special Reporting Requirements ...... 25 Health ...... 25 9.3 Success Stories ...... 31 9.4 Stakeholder Engagement to Foster Collaboration, Coordination, and Adaptive Management ...... 34 9.5 Activity Learnings and Adaptions in Past Periods ...... 37 9.6 Updated Learning Agenda Schedule ...... 40

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ACRONYMS AND ABBREVIATIONS

ADHO Assistant district health officer AMELP Activity Monitoring, Evaluation, and Learning Plan ANC Antenatal care ANC4 Four antenatal care visits ART Antiretroviral therapy BEmONC Basic emergency obstetric and newborn care CDCS Country Development Cooperation Strategy CEMONC Comprehensive emergency obstetric and newborn care CHC Communication for Healthy Communities CHI Community health insurance CHW Community health worker CME Continuing medical education DHIS District Health Information System DHO District Health Office DHIS2 District Health Information System 2 DHMT District Health Management Team DHT District Health Team EDHMT Extended District Health Management Team EMTCT Elimination of mother-to-child transmission EOP End of project FP Family planning HC Health center HIV Human immunodeficiency virus HMIS Health Management Information System IEC Information, education, and communication IP Implementing partner IPT Intermittent preventive treatment IR Intermediate result IVEA Independent Verification and Evaluation Agency K&L Knowledge and learning MCH Maternal and child health MHealth Mobile health MNCH Maternal, neonatal, and child health MOH Ministry of Health MPDSR Maternal and perinatal death surveillance and response MTCT Mother-to-child transmission OBA Output-based aid OIG Office of Inspector General PNC Postnatal care PPFP Postpartum family planning PPPH Public-private partnerships for health PRS Performance Reporting System QI Quality improvement RBF Results-based financing RHITES Regional Health Integration to Enhance Services RMNCH Reproductive, maternal, neonatal, and child health SBCC Social and behavior change communications SBCCO Social and behavior change communications officer

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SDA Safari Day Allowance SGBV Sexual and gender-based violence SQIS Self-Regulatory Quality Improvement System TBA Traditional birth attendant UDHS Uganda Demographic and Health Survey UGX Ugandan shilling UHF Uganda Healthcare Federation URMCHIP Uganda Reproductive, Maternal, and Child Health Services Improvement Project USAID United States Agency for International Development USD United States dollar USG United States Government UTI Urinary tract infection UWOPA Uganda Women Parliamentarians Association VCBD Voucher community-based distributor VHT Village Health Team VMA Voucher Management Agency VMIS Voucher management information system VSLA Village savings and loan association VSP Voucher service provider

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ACTIVITY INFORMATION

Activity Name: Uganda Voucher Plus Activity Project: The Voucher Plus Activity is a five-year (2016–2021) project of USAID that aims to increase use of health services for pregnant women by promoting safe, facility-based deliveries among poor women to reduce maternal and neonatal morbidity and mortality in Eastern and Northern Uganda. Activity Start Date and End January 29, 2016–January 28, 2021 Date: Name of Prime Abt Associates Implementing Partner: [Contract/Agreement] AID-617-LA-16-00001 Number: $24,499,611 Name of Sub-awardees and Communication for Development Foundation Uganda – UGX Dollar Amounts: 5,913,526,140 (approx. USD1,845,670) PricewaterhouseCoopers–UGX 10,148,838,667 (approx. USD 2,899,668) Plus provider reimbursement UGX 29,520,000,000 (approx. USD 9,000,000). BDO Uganda–UGX 2,913,532,719 (approx. USD 859,789). Major Counterpart Ministry of Health (MOH), District Health Management Teams (DHMTs), Organizations: World Bank (WB), Marie Stopes Uganda (MSU), Regional Health Integration to Enhance Services (RHITES), implementing partners (IPs), and Communication for Healthy Communities (CHC) Geographic Coverage Agago, Alebtong, Amuria, Amuru, Apac, Budaka, Bulambuli, Bukedea, (districts; also, note any Butebo, Butaleja, Dokolo, Gulu, Kaberamaido, Kapchorwa, Katakwi, changes): Kitgum, Kole, Kumi, Lamwo, Lira, Manafwa, Mbale, Ngora, Nwoya, Omoro, Otuke, Oyam, Pader, Pallisa, Serere, Sironko, Soroti, Namisindwa, Kwania and Kapelebyong. Reporting Period: October 1, 2018 – December 31, 2018

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1. ACTIVITY INTRODUCTION

1.1 Activity Description

The Uganda Voucher Plus Activity (the Activity), led by Abt Associates, provides quality obstetric, newborn, and postpartum family planning (PPFP) services to very poor Ugandan women in the North and East. The Activity improves health equity by ensuring the poor in 35 districts have access to information and services for healthy pregnancies and deliveries. The Activity identifies and accredits private providers to deliver a package of services, for which the providers are reimbursed by the Activity. Simultaneously, the Activity works with community volunteers, including Village Health Teams, who sell vouchers at 4,000 Ugandan shillings (UGX) to women who qualify, while also providing safe motherhood information to local populations. The voucher service package includes four antenatal care (ANC) visits; elimination of mother-to-child transmission (EMTCT) of HIV services; delivery with a skilled birth attendant and referral for complications, postnatal care, and postpartum family planning. By targeting very poor women to receive the voucher, the Activity seeks to provide financial protection to this vulnerable population to avoid catastrophic out of pocket payments. The Activity strengthens the capacity of participating private providers through clinical and administrative mentoring, supervision, and auditing to improve service quality. The Activity also ensures providers contribute to the district health management information system, and it addresses other facility gaps. The Activity actively engages District Health Offices to build capacity of private providers, stimulating private-public partnerships for health that ultimately strengthen district health systems. The Activity leads training for providers, allowing them to learn the necessary skills in managing timely and correct claims submission and reimbursement that will allow for future participation in Ministry of Health (MOH) health financing mechanisms. Finally, the Activity contributes evidence on output-based health financing mechanisms in Uganda to support the MOH to efficiently implement health financing mechanisms. The Activity will achieve its overall goal of increasing access to safe delivery through two Intermediate Results (IRs):  Increased use of high-quality voucher-covered reproductive, maternal, neonatal, and child health (RMNCH) and family planning (FP) services in designated program districts  Increased capacity of public and private sector to develop longer-term health financing options The targets for this Activity are:  Provide at least 250,000 safe deliveries.  Ensure at least 50 percent of all women with vouchers access four antenatal care (ANC4) visits.  Enroll 100 percent of HIV-positive pregnant women in EMTCT services.  Increase postnatal care (PNC) services to cover at least 50 percent of women who deliver with a voucher, and their babies.  Provide postpartum family planning services for 50 percent of women who deliver with a voucher. Voucher Plus activities are implemented in close collaboration with MOH and district health teams. Synergies with stakeholders are optimized, especially with other USAID implementing partners (IPs), the MOH/World Bank Reproductive Health Voucher Project and other health and non-health organizations. Annex 8.1 contains a Gantt chart showing the approved work plan for Year 4 (Y4)

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1.2 Performance Analysis to Date

Performance Management Plan/Project Indicator Progress—USAID Standard Indicators and Project Custom Indicators Strategic Objective: Provide measurable improvements in safe motherhood services by supporting health financing and innovative service delivery models in the private sector Quarterly Baseline Data Year 4 Status – Year 4 Annual Annual Performance CDCS Link Indicator Annual Comment(s) Cumulative Achieved to Year Value Cumulative Q1 Planned Date (%) Actual Target1 2.1 and 2.2 Number of deliveries in 2016 0 64,320 21,659 21,659 34% Performance represents 135% achievement of quarter’s participating facilities that target and 34% of the annual target. The over- are paid for by the Voucher achievement is due to the fact that as the Activity has Plus Activity matured, more women are aware of the importance of delivering at facilities. Another factor is that data reported are from providers’ claim forms, some of which are late submissions from last quarter that missed the cutoff date. Rate of cesarean section 2016 0 12% 9.5% 9.5% Overall, caesarean section rates for the Activity are within the MOH recommended rates of not higher than 10- 15% Facility still birth rate (per 2016 0 10 7.5 7.5 Performance is strong compared to the national facility 1000) still birth average of 9.4 per 1,000 births as per Annual Health Sector Performance Report-AHSPR of 2017/18 Percent of deliveries 2016 0 100% 100% 100% Observed performance is explained by the fact that all attended by skilled health deliveries paid for by Voucher Plus are attended to by personnel skilled health personnel at the supported facilities. Percentage of births 2016 0 100% 135% 135% Because the denominator is the targeted number of delivered at a health facility facility deliveries using a voucher, the performance on this indicator is explained by the same factors as number of deliveries at participating facilities. Percentage of mothers 2016 0 90% 93.1% 93.1% initiating breastfeeding within 1 hour after birth

Percentage of women who 2016 0 50% 40% 40% The underperformance for this indicator is because the attended at least ANC4 majority (over 80%) of clients purchase vouchers late in during pregnancy pregnancy due to socio-cultural norms such as reluctance to reveal pregnancy early, making it difficult to complete the 4 antenatal visits before delivery.

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Quarterly Baseline Data Year 4 Status – Year 4 Annual Annual Performance CDCS Link Indicator Annual Comment(s) Cumulative Achieved to Year Value Cumulative Q1 Planned Date (%) Actual Target1 Percentage of pregnant 2016 0 100% 70% 70% Underperformance here is explained by fact that many women living with HIV who voucher facilities are not accredited to offer antiretroviral received antiretroviral drugs drugs and therefore test for HIV and refer or link clients to reduce the risk of to nearby public sector facilities with antiretrovirals for mother-to-child transmission EMTCT enrollment. However the confirmation of client (MTCT) with HIV enrollment at the public facility happens after the client’s claim has been filled and sent for reimbursement. So the missing data represents clients whose enrollment status at public facilities had not yet been confirmed using the linkage mechanism the Activity established. Percentage of mothers 2016 0 45% 60% 60% The overachievement was due to improved client follow- receiving PNC check-ups ups and counselling on the need to utilize PNC services within six weeks of childbirth after delivery. Number of newborns not 2016 0 2,500 624 624 25% breathing at birth who were resuscitated in USG- supported programs Number of women giving 2016 0 64,320 13,867 13,867 21.5% The slight underachievement this quarter is due to poor birth who received completion of the claim forms by providers. Some delivery uterotonics in the third stage claims have missing data on uterotonic use, yet follow-ups of labor (or immediately looking at the maternity registers at facilities usually after birth) through USG- indicate mothers were indeed given uterotonics. supported programs 2.1.3 and 2.2.4 Number of individuals 2016 0 93,236 27,127 27,127 29% attending community mobilization events conducted to increase uptake of maternal health vouchers Number of vouchers 2016 0 123,061 29,217 29,217 23.7% Performance represents 95% achievement of the distributed quarter’s target and 24% of the annual target. Delayed provider reimbursements during the quarter affected their ability to buy more vouchers. Number of USG-assisted 2016 0 650 585 585 90% community health workers (CHWs) providing FP information, referrals, and/or services during the year USAID|Uganda Voucher Plus Activity 3 3

Percentage ANC1 0 95% 73.3% 73.3% The Activity achieved ANC2, ANC3, delivery, and PNC of vouchers targets. The underachievement for ANC1 was related to ANC2 0 60% 71.3% 71.3% redeemed the December holidays, when some clients’ routine visits ANC3 0 60% 63% 63% to facilities decline. Also, based on good obstetric practice, ANC4 0 50% 40% it is not feasible to have clients who enroll within a 2016 Delivery 0 70% 74.1% quarter go to facilities for 4 routine ANCs within the Postnatal 0 50% 60% 60% same quarter. Hence, it is best to gauge key service care utilization on a voucher Activity on an annual as opposed Postpartum 0 45% 17% 17% to quarterly basis. FP 2.1.2 and 2.1.4 Percentage of babies born 2016 0 100% 87.1% 87.1% The underachievement is due to incomplete to women participating in documentation on the claim forms by providers. Some the Voucher Plus Activity claim forms come with missing data on children’s started on immunization immunization initiation status. In addition, some facilities within six weeks of the link children for immunization at nearby public facilities postpartum period and so these records are not captured in our system. Percentage of USG-assisted 2016 0 75% 100% 100% The indicator definition in the Activity Monitoring, service delivery sites Evaluation, and Learning Plan (AMELP) does not match providing FP counseling the definition in the Performance Reporting System (PRS). and/or services Previously we have excluded all the Catholic facilities from the numerator, but the PRS definition considers them as well; hence the overachievement now that all voucher service providers (VSPs) are included. We will revise the indicator definition in the next revision of the AMELP. Number of USG-supported 2016 0 112 155 155 138% More facilities were recruited during the last project year service delivery points than anticipated, hence the overachievement. offering any modern contraceptive method among postpartum women

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Quarterly Baseline Data Year 4 Status – Year 4 Annual Annual Performance CDCS Link Indicator Annual Comment(s) Cumulative Achieved to Year Value Cumulative Q1 Planned Date (%) Actual Target1 Percentage of women who 2016 0 100% 91% 91% One-third of VSPs are Catholic facilities and do not received postpartum provide FP services. FP utilization is also very low partly counseling for FP because of household power dynamics regarding FP use, as well as community myths about FP. Number of clients provided 2016 0 32,160 2,548 2,548 8% FP services

Percentage of pregnant 2016 0 90% 128.1% 128.1% The number of clients receiving IPT3 is greater than the women who received three number who received ANC4 services, which is the doses of intermittent denominator. Because the majority of clients buy preventive treatment (IPT) vouchers late in pregnancy, it is likely that the majority of for malaria clients complete the ITP3 dose in their third visit and deliver before completing the fourth antenatal care (ANC) visit. 3.3 3.3.1 and 3.3.5 Number of private facilities 2016 0 120 143 143 119.2% By the end of the quarter, 143 of 155 providers were that report data on health actively reporting facility data into the District Health indicators into the DHIS2 Information System 2 (DHIS2). Overachievement is due Percent timeliness of health 2016 0 100% 95.5% 95.5% to the fact that more facilities were recruited than facility Health Management anticipated. Information System (HMIS) reporting 3.3.5 Number of voucher- 2017 0 - 0 0 0% The focus of the Activity changed from linking mothers to supported mothers linked to VSLAs to a more sustainable, provider-led model. The existing local village savings Activity is building capacity of the supported facilities in and loan associations the two regions to take on community-based health (VSLAs) to encourage saving insurance schemes in which the vulnerable women and for their health their households will be targeted and enrolled. With their Proportion of voucher clients 2017 0 - 500 500 0% scant resources thus pooled, they will be able to access linked to local VSLAs that essential health care even beyond the Voucher Activity. report to be actively saving During the last quarter, over 500 members joined, each for their health within the contributing 10,000/= for membership fees per schemes household and then 10,000/= to cover treatment for 6 months.

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2. ACTIVITY IMPLEMENTATION PROGRESS

2.1 Summary of Implementation Status Summary of Planned Activities Shifted IR Actual Achieved in Quarter Activities in Quarter to Next Period IR 1: – Create demand for RMNCH – Distributed 29,172 vouchers to eligible – 1,594 unsold Increased use services and distribute women vouchers are carried of high-quality vouchers. – Reached 35,893 people via community forward voucher- – Conduct client follow-ups to events – Improve medicines covered improve service redemption. – Held nine radio talk shows to encourage management at MNCH and FP – Provide hotline services. redemption VSPs health services – Conduct on-site in designated – Improve quality of care at – Distributed 401 T-shirts, 3,503 CME on SGBV and program facilities through on-site information, education, and youth-friendly districts mentorship and technical communication materials with pregnancy support supervision. danger signs, and 3,722 pregnancy care services – Collaborate with other IPs to planners and voucher community-based – Completion of SQIS increase efficiency. distributor (VCBD) tools rollout – Conduct joint facility monitoring – Conducted 7,676 client follow-ups visits with district health officers – Provided hotline services for 771 people – Conduct continuing medical – Provided 107 on-site mentorship visits education (CME) on sexual and reaching 267 providers gender-based violence (SGBV) – Worked with Regional Health Integration and youth-friendly services. to Enhance Services- East (RHITES-E) on – Introduce use of the Self- maternal and perinatal death surveillance Regulatory Quality and response (MPDSR) and access to Improvement System at health EMTCT facilities – Conducted 22 joint support supervision – Improve medicines visits with district health teams management at VSPs. – Made 36 visits to 21 district health offices – Improve service to brief district health officers on Activity linkages/referrals. implementation progress – Strengthen data capture, use, – Introduced Self-Regulatory Quality and reporting into DHIS2 by Improvement System (SQIS) at 124 of the private facilities. targeted 153 facilities. 504 health workers were reached in SQIS implementation at the 124 facilities. – Engaged district health officers and biostatisticians, resulting in inclusion and activation of eight voucher facilities into DHIS2 in six districts – Engaged biostatisticians and HMIS focal persons in 35 districts for HMIS supportive supervision across voucher facilities – Improved linkages to ambulance, immunization, and EMTCT services between private and public facilities

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Summary of Planned Activities Shifted IR Actual Achieved in Quarter Activities in Quarter to Next Period IR 2: – Support and graduate VSPs – Supported 15 VSPs that qualified to join – Increase access to Increased with improved quality of care phase one of RBF project following MOH’s VSLAs for poor capacity of into results-based financing phase 1 assessment in 26 districts women to save for Uganda’s (RBF). – Together with MOH, developed a Uganda health public and – Facilitate the public-private Reproductive, Maternal, and Child Health – Develop partnership private sectors partnerships for health in the Services Improvement Project (URMCHIP) with Health Partners to develop districts. and Voucher Plus coexistence framework International to longer-term – Strengthen district health that will eventually see transition of some continue to build health management teams’ VSPs into MOH’s RBF by end of project interested VSPs’ financing understanding of RBF (EOP) capacity in options mechanisms through active – 19 VSPs attracted to private health community health engagement in voucher insurance as a result of participating in the insurance activities. Voucher Plus Activity. – Continue dialogue – Together with RHITES and – Actively engaged extended district health with the district health offices (DHOs), management teams (EDHMTs) in voucher MOH/World Bank strengthen MPDSR in VSPs. activities, which strengthened their RBF technical – Share quarterly performance understanding of RBF working group and reports with districts. – Documented provider investments into stakeholders on sustainability of – Encourage, monitor, and their infrastructure for at least 14 facilities vouchers after the document provider investments – Shared quarterly reports with DHOs end of the project, into their facilities. – Shared with AOR learning reports on and how more VSPs – Increase access to VSLAs for provider assessment and accreditation can be included in poor women to save for health. process, and rapid cycle learning on the MOH/World – Implement the learning agenda reasons for low service redemption Bank program. and disseminate learnings. – Facilitated VSP learning on community – Ensure that the health insurance (CHI) through remaining VSPs not participation of 17 VSPs in the 3rd yet added to the national CHI conference. national HMIS are – Three VSPs wrote concepts papers on finally added. starting CHI in their communities. One – Continue advising VSP (Alleluyah Joint Medical Clinic) VSPs in investing enrolled 500 members in a CHI scheme. income into facilities – Continued finalizing rapid cycle learning to make lasting reports on client satisfaction, demand improvements, and generation, interest/ability to pay for the documenting the voucher and services, and targeting with improvements to the use of poverty grading tool facilities and business practices.

2.2 Progress Narrative

This quarter marked the start of the fourth year of the Voucher Plus Activity. The Activity made tremendous progress towards achieving its targets and deliverables over this quarter. Below is the quarterly progress update by intermediary result (IR) area. See more information in Section 8.

IR 1: Increased Use of High-Quality Voucher-Covered MNCH and FP Services in Designated Program Districts Sub-IR 1.1: Demand for MNCH and FP Services in the Private Sector by the Poor Created in Designated Program Districts During the reporting period, the Activity distributed 29,172 vouchers (95 percent of the quarterly target). The total voucher sales for quarter 1 are 23.7 percent of the annual target, while cumulative sales from Activity inception stand at 261,330 (~73 percent of the end-of-project target of 360,000). The Activity teams will distribute the remaining 98,670 vouchers during the remaining quarters of Year 4 to allow time for intensified client follow-up in Year 5. The Activity reached 35,893 people (153 percent of the target) with RMNCH messages through community mobilization events, and distributed RMNCH information, education, and communication materials. A total of 14,268 youth (184 percent of the target) were reached through dialogues to discuss sexual and reproductive health issues and address myths regarding family planning. Sub-IR 1.2: Access to Comprehensive MNCH and FP Services in the Private Sector Improved The Activity improved access to voucher services at 153 facilities in 35 districts. VSPs continued to improve quality by investing earnings to improve infrastructure, buy equipment, and hire additional staff. Table 1 shows major investments made by 14 facilities to improve access to more comprehensive RMNCH services, including comprehensive emergency obstetric and newborn care (CEMONC). Table 1: Examples of VSP Investments in Infrastructural Upgrades to Improve Quality Facility Infrastructural Improvement in Y4 Q1 Alleluyah Joint Medical Clinic Completing construction of new facility with operating theatre Aloi Mission H/C Completing construction of staff quarters Bethesda Hospital Completed construction of a neonatal intensive care unit Bukedea Mission H/C III Constructing new maternity ward Bushikori H/C Recruited two additional midwives Kaucho Mission H/C III Expanded outpatient department Completed construction of ANC shaded areas for privacy and Kolonyi Hospital sun protection Kwera Maternity Home Completed construction of a new PNC ward Kyere Mission H/C III Completed staff quarters for midwives Completed maternity ward and procured immunization Lukodi H/C III refrigerator Mbale People’s Clinic Completing construction of new facility with operating theatre Pope Paul Memorial Hospital, Completed construction of a neonatal intensive care unit Aber Prof Wamukota H/C Procured new ambulatory vehicle St. Mary’s Hospital Lacor Constructing new maternity theatre

The adaptive programming strategies implemented during the reporting period have enabled the Activity to make significant improvements in service coverage, with the exception of FP use, which remains a challenge. The Activity enabled 21,659 clients (34 percent of annual target) to access facility-based delivery using a voucher. This brings the cumulative number of deliveries since inception to 118,408. DHIS2 statistics for the 35 supported districts show that the Activity accounted for 32 percent of all facility-based deliveries recorded in Year 4 Quarter 1 (Y4Q1). With support from Voucher deliveries DHOs and implementing partners like TASO Gulu and the accounted for 32 Regional Health Integration to Enhance Services (RHITES) Activities, the Voucher Plus Activity continued to strengthen percent of all facility- service linkages between private facilities and nearby public based deliveries across facilities, especially for ambulance, EMTCT, immunization, and FP the 35 voucher districts services. in the first quarter of The implementation of voucher services within private wings of four public facilities has improved access to CEMONC services, Year 4. and has also built the capacity of public health providers to implement output-based aid (OBA) mechanisms Sub-IR 1.3: Quality of MNCH and FP Services at Participating Private Sector Facilities Improved The Activity continued to offer technical support to health facilities to improve quality of care. This has also served to greatly improve providers’ understanding of the role of both quality and quantity measurements in OBA mechanisms. During the quarter, the Activity introduced the Self-Regulatory Quality Improvement System (SQIS) at 124 facilities, bringing the cumulative number of facilities reached to 132. The average score for the 124 facilities at the initial SQIS assessment was 67 percent. The Activity will facilitate having providers carry out self-assessments every six months as per the SQIS requirements. During the quarter, a total of 504 health workers were oriented on how to conduct SQIS at their facilities, bringing the cumulative number of health workers reached to 538. SQIS enables providers to ensure internal quality assurance. The Activity also conducted 107 on-site mentorship visits, reaching 267 providers. Three quality improvement projects were initiated by VSPs, while 19 previously started quality improvement projects were reviewed by clinical teams. In partnership with RHITES IPs and regional referral hospital teams, the Activity is supporting private providers to implement the revised maternal and perinatal death surveillance and response guidelines. Activities to strengthen the referral network for CEMONC services were implemented this quarter based on the findings from the last annual clinical audit. These activities were initiated through a technical review meeting with 23 facilities (including 4 public facilities) that refer to St. Mary’s Hospital, Lacor. Meeting participants agreed on resolutions to improve the referral system, with the result that there were no maternal deaths recorded at the hospital in the months of October and November. Similar technical meetings were held in the East at Kolonyi Hospital, yielding similar results. Together with district health leadership and RHITES Activities, the Voucher Activity will continue to encourage improved engagement of CEMONC facilities and basic emergency obstetric and newborn care (BEmONC) facilities across their referral networks.

The Activity discontinued voucher provision services at three VSPs. This was due to their continued failure to implement agreed-upon quality improvement plans to address poor quality of care and their noncompliance with Activity standard operating procedures, despite all the support provided over time.

IR 2: Increased Capacity of Uganda’s Public and Private Sectors to Develop Longer-Term Health Financing Options Sub-IR 2.1: Local organizations with the capacity to implement output-based financing activities strengthened In Year 4, the Activity will play a larger role in strategic partnerships for sustainable development among providers and district leadership. We will strongly emphasize vouchers as a stepping stone to future strategic financing options, and we will encourage districts, VSPs, and communities to embrace opportunities for stronger collaboration and innovation. The Activity continued to build local capacity to implement other health financing mechanisms by collaborating with DHOs, engaging public facilities, and fostering stronger linkages and partnerships at district levels. In all of these efforts, the Activity emphasized high quality and improved VSP management systems. Activity staff and VSPs participated in five quarterly district IP and Extended District Health Management Team (EDHMT) meetings, where they shared information on strategic purchasing and on how vouchers complement current financing mechanisms to increase access to RMNCH services. The Activity continues to build stakeholder capacity in output-based financing strategies, including demand- and supply-side results-based financing, and how together they can be used to increase uptake of health services, especially among the very poor. We continued our efforts to prepare the district and national government stakeholders and providers for RBF and the national health insurance scheme by emphasizing the importance of joint supervision, clinical auditing, data management, strengthened referrals to improve the patient pathway, and increased health awareness to build demand for quality services. Results from these efforts are beginning to show. For example, in the recently conducted MOH-RBF prequalification assessments in 26 phase 1 districts, all 15 voucher-supported postnatal FP facilities assessed qualified to join the government RBF scheme. The Activity and District Health Team members conducted 22 joint health facility visits for supportive supervision, provider mentorships, SQIS rollout, and monitoring of service quality. By the end of the quarter, 19 VSPs were engaging in private health insurance. Activity staff and VSPs participated in five quarterly district IP and EDHMT meetings, where they shared the benefits of strategic purchasing and how vouchers complement current financing mechanisms in the public sector to increase access to RMNCH. The Activity continued working with the biostatisticians to support private facilities in improving data use, consistency, and accurate reporting into the DHIS2. During the quarter, the Activity worked with DHOs and biostatisticians to ensure inclusion and/or activation into the DHIS2 for eight voucher facilities in six districts. At this time, 143 VSPs are fully connected and reporting to DHIS2. This quarter the Activity allowed biostatisticians to conduct HMIS supportive supervision independently in private facilities, without involvement of Activity staff. This move was aimed at improving perceptions and relationships between VSPs and biostatisticians, and was greatly appreciated by the DHOs. By the end of Year 4, the Activity aims to have all VSPs accurately reporting to the districts through the HMIS in a timely manner, under the supervision of their respective biostatisticians. We also continued to build the public sector’s capacity to operate private wings, allowing them to generate additional income to augment facility services. We are training these public facilities in claims management and selective contracting, which are critical capacities for participating in national health insurance programs. Additionally, capacity building allows regional referral hospitals to better understand the private sector’s technical requirements, gaps, and/or needs, and thereby offer more targeted technical support to lower-level facilities. This quarter, the Activity paid UGX 2,741,874,361 to facilities as reimbursements for services offered (compared to UGX 2,124,091,560 the previous quarter). As illustrated in Table 1, above, VSPs have

invested these earnings to improve quality, primarily through improving infrastructure and hiring additional staff. Building on community exposure to reproductive health vouchers, the Activity collaborated with Save for Health 500 households Uganda to promote community health insurance. After registered for a participating in the national health insurance conference in November 2018, Alleluyah Medical Center adopted lessons community health learned and engaged Alebtong district leaders and community insurance pilot as a result leaders to mobilize participants for community health insurance. Five hundred households have been registered in a of collaboration between pilot scheme that began on January 1, 2019. The Activity, in Alleluyah Medical Center collaboration with Save for Health Uganda, will evaluate the and Alebtong district implementation of the scheme and encourage scale-up among other VSPs. leaders. Sub-IR 2.2: Evidence, data, and assistance to develop sustainable financing schemes for MNCH and FP provided The Activity continued actively participating in the monthly RBF IP forum for knowledge sharing and learning at the MOH. The Activity worked with the MOH RBF team to develop a framework for the coexistence of voucher and RBF mechanisms in districts where Voucher Plus and the MOH’s RBF program operate simultaneously. The framework has been approved by the MOH and is set for implementation in the second phase of RBF rollout, due in April 2019. We also made progress this quarter on three additional knowledge and learning studies: client satisfaction, the effectiveness of the poverty grading tool in targeting beneficiaries, and the effectiveness of demand- generation activities in recruiting clients. Based on data collected in the last quarter of Year 3, we conducted data analysis and drafted briefs. These drafts are currently under internal review. We will use the findings to adapt programming, strengthen the evidence base, and share knowledge with the MOH and other IPs implementing RBF and other financing methods. The Activity also began conceptualizing a rapid cycle implementation research study to document the lessons learned, challenges, and opportunities in the Activity’s interventions to ensure the quality of VSP services.

3. GUIDING PRINCIPLES

3.1 Partnership, Collaboration, and Stakeholder Engagement

The focus of the Voucher Plus Activity’s stakeholder engagement work is sustainable change. In line with the Uganda Country Development Cooperation Strategy (CDCS) 2.0 guiding principle 6, we are increasingly intent on developing strategic partnerships that enable Ugandan-led development, and on clear rules of engagement to achieve shared goals for the advancement of universal health coverage in Uganda. This quarter, our strategic engagements resulted in the following key achievements: Development of the Uganda Reproductive Maternal Child Health Services Improvement Project (URMCHIP) and Voucher Plus coexistence framework. Concerned that the existence of two financing mechanisms would create competition, lead to duplication of effort, and threaten public-private partnerships for health, the Activity spearheaded discussions about coexistence of the World Bank-funded URMCHIP and the Voucher Plus Activity. As mentioned above, the Activity worked with the MOH RBF Unit to develop a coexistence framework that defines and guides rules of engagement and opportunities for collaboration. The purpose of framework is to streamline the mechanisms of a synergistic coexistence

in the districts and/or facilities where the Voucher Plus Activity was operating before the URMCHIP rollout. The framework was approved by the MOH and is expected to take effect in the next quarter. The Activity will actively learn from successes and challenges, and make adaptations to ensure that the two RBF mechanisms are implemented synergistically. Stimulated VSPs’ capacity to develop and start implementing innovative health financing mechanisms. The Voucher Plus Activity partnered with Save for Health Uganda to organize the 3rd National Community Health Financing Conference, which took place in November 2018. The Activity continues to be a key stakeholder and active participant in various forums that relate to the future health financing landscape in Uganda, including the national health insurance scheme, RBF, community health insurance, health cooperatives, and others. Our participation in the 3rd national CHI conference promoted voucher schemes as an instrument of RBF and an effective health financing mechanism for poor populations. In addition, and mindful of CDCS 2.0 guiding principle 7, the Activity motivated VSPs to integrate additional financing mechanisms to enable continuity of services while preparing them to participate in Uganda’s future health financing mechanisms. The Activity supported the participation of 17 VSPs in the conference, allowing them to learn from the best practices in CHI implemented by local partners in Uganda. This was the first time the conference had participation from the east and northern regions. Since the conference, the VSPs have promoted health saving behaviors and practices among voucher clients and their families. By December 2018, three VSPs had developed concepts for starting CHIs in their communities. The Activity will partner with Save for Health in Uganda to steer these adaptions as a sustainability measure for the VSPs. Facilitated district leadership efforts to address HMIS challenges in VSP facilities. In line with CDCS 2.0 guiding principles 6 and 11, the Activity facilitated health management information system supportive supervision of 156 VSPs by district biostatisticians and/or HMIS focal persons in 35 districts. The Activity also strengthened relationships between VSPs and biostatisticians to foster sustainable improvements in accurate and timely HMIS reporting. The Activity will continue to steer HMIS strengthening as we transition this role to the district leadership by the end of the Activity. 3.2 Learning and Adaptation

Stakeholder forums to discuss and identify local solutions to maternal and newborn outcomes arising from poor referral practices. During various MPDSR meetings at the district level, it was noted that the majority of poor maternal and newborn outcomes resulted from ineffective or late referrals. Mindful of CDCS 2.0 guiding principle 5 (“Seek to ‘do business differently’ when current mechanisms, concepts, operations, and tools do not work”) and guiding principle 15 (“foster leadership as a lever for change – within the Agency, with partners and with stakeholder”), the Activity spearheaded a regional forum between public and private facilities to discuss and identify local solutions to the persistent challenge of referrals. Following the successful meeting held at Kolony hospital for the eastern region in Year 3 Q4, the Activity replicated the forum in the northern region this quarter. The first meeting, held at St. Mary’s Lacor Hospital, attracted four public facilities and 24 VSPs, along with DHOs, health sub-district officials, and RHITES-Acholi. The outcomes of this meeting included:  Improvement in referrals as referring facilities (including public facilities) received feedback on where they need to act  Improved relations among referring and referral facilities  Improved outcomes for mothers and children. For example St. Mary’s Lacor Hospital reported three maternal deaths in August (inclusive of non-voucher clients), six maternal deaths in September, and no maternal deaths in October and November 2018 following the meeting. The Activity plans to conduct similar forums in Soroti, Apac, and Lira in Y4 Q2.

In collaboration with DHOs and RHITES, the Activity will continue to steer these forums on a quarterly basis. We will also take several steps to ensure that these forums are sustained:  DHOs and health sub-district officials will manage these meetings in Year 5.  The Activity will continue to emphasize cost sharing, with meeting facilities and logistics provided by the host facility.  Meetings will be rotated between facilities to avoid financial burdens on one hosting facility.

Introduction of mobile health (mHealth) solution to enable real-time data reporting: The Activity uses a computer-based claims processing and database management information system for processing claims submitted by VSPs. It also supports verification of voucher processes for sales, service provision, and quality assessment and reporting. However, the current data reporting processes do not provide real- time data for timely management action, due to the time required for the transfer of paper records from remote areas to Kampala and delays in subsequent data entry and vetting. These challenges have also lead to under-reporting of performance in the current quarter for quarterly reports and the PRS system, with claims processed instead in the following quarter. In November 2018, the Activity began piloting an mHealth solution. This solution features an efficient SMS platform that enables real-time submission of voucher sales data directly from VCBDs, permits daily analysis of voucher sales, and enables instant VCBD stock tracking and redemption monitoring. VSPs are also able to submit data on services redeemed using the voucher. The system is expected to be fully functional by the end of Y4 Q2, after all users are trained. 3.3 Inclusive Development

As in previous quarters, the Activity continued to engage youth, women, and men in administrative and various field-based social and behavior change communications (SBCC) and service delivery activities. The Activity employs youth in the claims processing and management. Many are recent graduates from university or schools of nursing and midwifery. The Voucher Management Agency (VMA) staff remains predominantly female as of December 31, 2018: 73 percent female and 17 percent male. The Activity remained keen on employing young people to undertake SBCC activities. Of the 19 additional VCBDs recruited in the quarter, nine were younger than 35 years old (five women, four men). Ten women were hired as new VCBDs, bringing the total number of women VCBDs to 233 out of 818. SBCC activities reached a total of 14,268 youths (6,313 men and 7,955 women) with RMNCH information.

4. LEADERSHIP AND DEVELOPMENT

During this quarter, all Activity staff received refresher fraud training conducted by the U.S. Foreign Service Officer from the Office of Inspector General (OIG). The training covered aspects of fraud detection and mitigation, and explained the responsibility of each staff member in preventing and reporting fraud.

5. HOW HAS ACTIVITY ADDRESSED AOR FEEDBACK FROM LAST QR?

Not applicable this quarter.

6. SUMMARY FINANCIAL MANAGEMENT REPORT

Activity Financial Analysis a. Total estimated cost (life of activity) $24,499,610 b. Start/end date Start: Jan. 29, 2016 End: Jan. 28, 2021 c. Total obligated amount (to date) $16,415,000 d. Total estimated cost share expected over the life of the activity (if applicable) $1,549,140 e. Total actual cost share to date (if applicable) $1,305,515 f. Total estimated leverage expected over the life of the activity (if applicable)2 g. Total actual leverage to date (if applicable) h. Total expenditure invoiced to USAID/Uganda to date $12,768,135 i. Expenditure incurred but not yet invoiced $417,331 j. Total accrued expenditure (both invoiced and not invoiced); sum of lines h and i $13,185,466 Actual Projections for the Next Three This Quarters Quarter Quarter 1 Quarter 2 Quarter 3 Quarter 4 Average quarterly expenditure rate by funding source $1,990,742 $1,967,615 $2,083,055 $2,083,055

2 Cost share (also known as “match”) refers to that portion of an activity cost not borne by the Federal Government, and is normally associated with contributions from the prime and sub-recipient sources that receive USAID funds. Leverage also refers to that portion of activity costs not borne by the Federal Government, but it is normally associated with the new, non-public resources – whether money, technologies, or expertise – brought by the private sector and other non- traditional USAID resource partners that are not receiving USAID funds. This is typically done through partnerships with the private sector. Cost share, which must be verifiable from the recipient’s records, is subject to the requirements of 22 CFR 226.23 and is subject to audit. Leverage is not subject to these requirements and is not subject to audit, although it must be verifiable. ADS 303.3.10 provides additional information about cost share and leverage under assistance instruments.

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7. MANAGEMENT AND ADMINISTRATIVE ISSUES

7.1 Key Management Issues

Bicycle donation to support community activities. The Activity received the donation of 150 bicycles from World Bicycle Relief in December 2018. The bicycles are being stored at two VSP facilities: Soroti Medical Associates (East) and Lacor hospital (North). The Activity is planning two handover events (one for each region) in February 2019.

Voucher management capacity and provider reimbursements. The Activity continued to reimburse VSPs for claims submitted for provided voucher services. In Y4Q1, the Activity reimbursed UGX 2,741,874,361 to VSPs for services provided to voucher clients, representing a 29 percent increase against last quarter’s UGX 2,124,091,560. The increase is attributable to a high volume of claims and a temporary enhancement in claims processing capacity (the Activity hired interns in Year 3 Q4 for one month to support data entry).

A major challenge the Activity continued to handle this quarter was claims processing capacity. The increased level of SBCC and service delivery activities in Year 3 raised demand for voucher services, and subsequently led to an unforeseen surge in claims received by the voucher management agency. The voucher management information system (VMIS) performance also slowed down due to an increased number of users, contributing to slower turnaround time for reimbursements to providers. The average reimbursement time increased from 25 to 65 days. The backlog in data entry resulted in under-reporting of the current quarter’s performance by about 30,000 client visits on some indicators that have age and/or facility-level disaggregation. Due to the reporting deadline of January 30, 2019, the Activity could not enter all the quarter’s data in time for analysis and reporting. Due to this constraint, data that was not yet entered into the VMIS for key indicators was physically counted to enable reporting for up to December 31 for those key indicators that do non require disaggregated data.

The Activity has assessed the expected data volumes for the remaining life of the project and designed a plan to resolve the capacity challenges. New claims processing staff will be hired and additional hardware procured during Y4Q2.

Independent verification and evaluation of the activity. The Independent Verification and Evaluation Agency (IVEA) is responsible for verifying accurate recording and reporting of services, activities, and accomplishments. The IVEA ensures that the Activity implements guiding principle 13 (“Incorporate anti- corruption mechanisms”) through the VMA claims processing work, and that it adheres to standard operating procedures. The IVEA reports that most facilities remained compliant with the minimum health system requirements during the quarter, despite reimbursement challenges. The quality of care was reported to be well above the minimum score of 70 percent in most facilities. The claims processing management audit also found that reported patients were obtaining the stated services.

Incident tracking and reporting. The Activity maintained a robust incident tracing system, whereby all Activity partners are encouraged to identify and report irregularities. A new hotline dedicated to reporting irregularities, 800239300, was secured and is being managed by the IVEA. The hotline number will be distributed to all VSP staff and other stakeholders responsible for mitigating incidents. During the quarter, the VMA’s claims processing identified suspected irregularities in the service delivery trends of eight providers. The suspected irregularities were reported through the Activity’s incident tracker and involved the providers listed in Table 2.

Table 2: Suspected Irregularities in Service Delivery Trends of VSPs

VSP Facility Identified Incident Kapuai Pacodet HC, Butebo District High cases of severe malaria on most claims Doctors' Clinic, Serere District Some clients redeeming vouchers on the same day they purchase them God’s Mercy, Nwya District High client volume for level of facility and high cases of malaria and urinary tract infections (UTIs) Beatrice Tierney Medical Center, Namisindwa Providers not indicating complaints for which District clients are treated on the claim forms Pabbo Maternity and Medical Clinic, Amuru District Claims show high incidence of complications with similar symptoms Hope Medical Clinic, Mbale District High client volume for level of facility, with most clients having complications; many clients with repeat illnesses previously successfully managed within short time periods; clients having similar symptoms Pallisa Genaral Hospital, Pallisa District Rude midwives, charging voucher clients for caesarian sections. Amucha SDA, Lira District High cases of malaria and UTIs on ANC claims Teso Safe Motherhood H/C, Soroti District Disproportionately high number of vouchers distributed for the number of VCBDs attached to the VSP.

The Activity quarantined reimbursements, suspended voucher distribution in some facilities, and commissioned the IVEA to do a follow-up investigation and verify reported cases. The verification reports will be reviewed in the next quarter and management action will be taken, including notifying the OIG as appropriate. 7.2 Resolved Management Issues

Recruitment: The Regional Clinical Quality Assurance Manager role for the northern region that fell vacant in Year 3 Q3 was filled this quarter. The Activity recruited for a new Monitoring, Evaluation, and Learning Director and selected an excellent candidate. He will join the Activity in February 2019. Streamlining SBCC activities: In tandem with CDCS 2.0, guiding principle 9 (“Maintain a problem-driven focus, while ensuring all program approaches analyze and adjust to the local context, at whatever level is required”) and guiding principle 11 (“Apply a facilitative approach to development, and minimize direct service provision over time”), the Activity reorganized the implementation strategy of SBCC activities to increase engagement of locally based VCBDs. Following the departure of two SBCC Officers, the scopes of work for the remaining three SBCC Officers and the SBBC Coordinator were revised to cover more districts.

8. PLANNED ACTIVITIES FOR NEXT QUARTER INCLUDING UPCOMING EVENTS

Planned Media/USG # Events/Activities in Next Quarter Involvement 1 Hold two regional events to launch the distribution of donated bicycles to Yes facilities to support VCBDs with demand generation and client follow-ups. 2 Implement the Activity Monitoring, Evaluation, and Learning Plan. Yes 6 Participate in monthly national RBF and MCH technical working group No meetings to promote Voucher Plus activities, collaborate with other partners, learn, and adapt new ideas. 8 Conduct demand-generation activities (community mobilization events, media No campaigns, voucher distribution, client follow-ups, etc.). 9 Conduct five media cafes (one per sub-region) to educate media about Yes RMNCH, share Voucher Plus success stories, and build positive connections with the media. 10 Provide ongoing technical support to strengthen quality of care at private No facilities (on-site mentorships, supervision, and monitoring). 11 Conduct data quality assessments at VSP facilities in collaboration with No district biostatisticians. 12 Implement SMS web-based system to monitor voucher sales and redemption. No 13 Commission the IVEA to audit 10 percent of claims processed for June No through September, and the claims processing system, for authenticity. 14 Receive, process, and reimburse providers’ fees for services offered. No 15 Conduct provider account reconciliations for quarantined and rejected No claims. 16 Procure storage facilities for used claims books. No 17 Facilitate learning and adaption on CHI for VSPs. Yes 18 Participate in national dialogues and symposiums relating to RMNCH, public- No private sector approaches, and health financing. 19 Participate in district meetings and dialogues on MNCH and other related No technical areas. 20 Coordinate with DHOs and resource center for inclusion of remaining 13 No VSP facilities not enrolled or active in DHIS. 21 Conduct monthly Activity partnership meetings to assess progress, learn from No implementation experiences, and adapt innovative new ideas (includes monthly and quarterly meetings with field staff and peer VCBDs)

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9. ANNEXES

9.1 Activity Work Plan

Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Activity Implementation and Quality Oversight Finance, administration, and logistics Deliver fraud prevention, detection refresher training for partners, including IVEA x-cut Conduct staff performance reviews Conduct monthly Voucher Plus Activity partner coordination meetings Voucher Plus Cooperative Agreement compliance Provide continuous collection and reporting on cost share Submit Quarterly Activity and Financial Reports to AOR Submit Annual Activity and Financial reports for Year 3 Implement EMMP and cascade to VSPs through mentorship and support supervision x-cut Train new staff on human trafficking, FP, and other compliance Conduct quarterly contract review—HQ and Uganda Voucher Activity Team Hold monthly AOR meetings to review Activity progress and address challenges affecting implementation Participate in USAID's monthly COP meetings Activity monitoring, evaluation, and learning Produce and disseminate timely routine and periodic progress reports based on AMELP indicators and donor reporting requirements to guide decision making and Activity implementation Strengthen the Activity’s demand for and utilization of data to guide and improve programming, planning and decision making processes Support districts to conduct HMIS supervisions x-cut and Data Quality Assessments to improve data quality and strengthen use of MoH HMIS tools to collect and report facility data, including DHIS2 system within voucher supported facilities Conduct Quarterly Performance Review Meeting Implement an SMS-based reporting mobile system to fast track voucher sales, distribution, and

redemption and provide real-time data on these processes

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Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Conduct targeted Data Quality Assessments to Partners and VSPs to follow up implementation of

actions and recommendations from Year 3 Data Quality Assessment activities Conduct client tracing and follow-up visits to ensure full voucher utilization and measure client satisfaction with voucher covered services Print and distribute HMIS Tools to VSPs Support implementation of the Peer VCBD approach to enhance VCBD monitoring, performance management, voucher sales, distribution, and redemption Independent Verification and Evaluation Agency Management/Communication Activities: Bi-weekly meetings with COP or Designee; Monthly Voucher x-cut Plus Activity Partner Meetings; Separate Learning Meetings between PwC & BDO Reports Monthly written project updates: Reports on any identified incidents; Technical and financial reports x-cut submitted with findings shared at Uganda Voucher Plus Activity meeting Verification tools Revise all existing Verification Tools; develop and use tools to examine quarantined claims for intensified incidence detection in first 10 facilities; x-cut revise tools for assessing quarantined claims at facility level on basis of findings; prepare report on intensified incidence detection in 10 private facilities Auditing of Claims and Claims Processes Audit claims and claims processes for period of October 2018-September 2019; audit report reviewing the findings of the claims processing system; contact 2% of beneficiaries of services from October 2018-September 2019; develop and test verification tools for assessment of scope and processes of ANC linked to financials; develop and x-cut test verification tools for the assessment of scope and processes of PNC; audit claims processing in 40 facilities; develop and test verification tools for the assessment of scope of FP; separate examination of incidents provided by partner; review quarterly trend analysis of project performance indicators Health Services Inspection and Verification Conduct provider service verification in 40 x-cut facilities; conduct desk-based review of training workshops and partner reports

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Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Voucher Management Agency Claims management software development & set-up x-cut Maintain and update VMIS at VMA office Voucher production Print vouchers and claims processing stationery x-cut Conduct Voucher verification Distribute vouchers to CDFU Voucher Service Providers Draft VSP contracts x-cut Sign contracts Management of providers claims and payments (reimbursements) Process claims Managing reimbursement of providers, handle x-cut rejected claims, and manage provider accounts reconciliations Data management and reporting Track voucher distribution and sales trends Track voucher redemption trends Monitor reimbursement trends ( e.g. % age of quarantines , rejects) x-cut Submit monthly reports to Abt Scan claims Archive files in the storage area Set up electronic filing system IR1: Increased Utilization of High-quality Voucher-covered MNCH and FP Health Services in Designated Program Districts SIR 1.1: Demand for MNCH and FP services in the private sector by the poor created: Promote the voucher scheme to increase demand for services Voucher distribution Design (adopt) and produce, print and distribute Voucher materials for VCBDs and private providers IR1 (DNIs and poverty grading tools) Equip contracted VCBDs with IEC materials and distribution tools Community mobilization and sensitization to increase demand for vouchers and promote utilization of voucher MNCH services Conduct community education sessions in collaboration with other partners Identify, select, and recruit additional VCBDs Renew contracts with trained VCBDs Conduct door-to-door mobilization and distribute IR1 vouchers to eligible clients in the community Conduct client follow-ups to ensure utilization of voucher supported services Track and monitor voucher distribution activities Hold sub-regional FP orientation meetings with VCBDs

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Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Carry out annual facility-community linkage meetings Facilitate SBCCOs to conduct monthly activities Conduct quarterly SBCC meetings in Kampala to review performance Reward VCBDs with certificates Share monthly client feedback reports Increasing awareness and knowledge for Voucher Plus Conduct mass media awareness and demand IR1 creation activities Provide on-going Hotline services SIR 1.2: Access to comprehensive MNCH and FP services in the private sector improved Provide and document on-site technical support to the four enrolled private wings of public facilities to improve CEmONC referral pathways for voucher clients Implement and strengthen the district-based ambulance referral network; work closely with the DHOs' offices to monitor the implementation of the ambulance referral system by VSPs to improve the referral mechanism for clients Increase access to eMTCT services by accrediting more private facilities as ART centers; work with IR1 DHOs and MoH AIDS Control Program team to re-assess and accredit private facilities that either missed the previous assessment or failed the assessments done in 2016 for ART accreditation to improve access to eMTCT for HIV positive clients Improve service linkages between private facilities and public sector for services not offered in the private sector; work with DHOs, public facility in- charges, and other partners like RHITES and VSPs to improve linkages between contracted facilities and public sector sites for ART, HIV tests, and vaccines for immunization SIR 1.3: Quality of MNCH and FP services at participating private sector facilities Improve VSPs' service delivery capacity Strengthen providers' technical competencies through on-site mentorships; conduct on-site mentorship/coaching to improve providers' competencies to offer quality EmONC and FP services Build capacity of providers to offer youth friendly IR1 services and address SGBV issues through on-site CMEs; conduct facility on-site CMEs on youth- friendly services and handling of SGBV issues Work with RHITES and DHOs' offices (through the District Laboratory Focal Persons) to strengthen the quality of providers' laboratory diagnostic services

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Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Strengthen providers involvement and interest in quality of care improvements through rolling out and monitoring the implementation of the MOH's Self Regulatory Quality Improvement System (SQIS) assessments by all VSPs Conduct annual clinical audits to check level of VSPs' adherence to MoH quality of care standards of care; collaborate with DHTs to conduct annual clinical audits to measure level of adherence to MoH standards of care and generate information for graduating private facilities into MoH GFF/RBF project Conduct Quarterly Technical support Visits to VSPs by DCOP and Quality Assurance Advisor to routinely monitor quality of care at facilities Conduct routine joint technical support supervision to VSPs together with DHOs' office and RHITES teams; work with DHTs and RHITES to develop joint annual supervision plan, conduct joint support supervision to all participating facilities on routine basis, and hold performance review meetings Facilitate VSP peer learning among low-performing and high-performing facilities; work with DHTs and RHITES IPs to support cross-site learning visits for quality improvements between low-performing and high-performing sites Strengthen medicines stock management at VSPs; work with RHITES and District Medicines Management Supervisors to improve medicines stock management at VSPs Foster private providers' participation in the quarterly district performance review meetings and/or region-based quality improvement meetings by the DHT and RHITES partners to bolster a CQI culture in VSPs Support facilities to adhere to the Environmental Management and Mitigation Plan(EMMP) best management practices Strengthen documentation, storage, and utilization of clients' data by all supported private providers IR2: Increased capacity of Uganda’s public and private sectors to develop longer-term health financing options SIR 2.1: Local organization/entities with the capacity to implement output-based health financing program strengthened Management of providers claims and payments/reimbursements, strengthening VSP abilities to manage claims Produce and distribute claims processing stationery to providers, and support in appropriate use IR2 Reimburse providers and handle quarantined claims and accounts reconciliations

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Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S Conduct quarterly field reconciliation visits to resolve unpaid quarantined VSP claims, provide on- site capacity building on record keeping and accurate claim generation practices Issue letters of continuity to VSPs to continue providing services under the current contractual terms Data management and reporting to improve VSP capacity, capacity of VHTs to target the right voucher beneficiaries, and the capacity of DHT's analysis of private sector areas for improvement Track voucher distribution and sales trends IR2 Track voucher service redemption trends Monitor reimbursement units and trends Improved capacity of private providers to participate in output-based payment mechanisms Renew provider contracts for Year 4; note contracts contain more detailed recommendations for investing profits, adhering to quality and health system improvements, fraud prevention and control Perform contracts management roles with VSPs; include handling provider reimbursements for service offered , handling rejected claims and accounts reconciliations Monitor improvements in providers' adherence to output-based financing contracts through reduction in rejected and quarantined claims on provider reimbursements. Encourage, monitor, and document providers' reinvestments of reimbursement profits into improving systems and quality of care at their facilities Facilitate supported private providers to report IR2 into DHIS2; work with District Biostatisticians and MOH resource center to include new VSPs into DHIS2, facilitate linkage between biostatisticians and VSPs for routine technical support to ensure timely, complete and accurate HMIS reporting and monitor providers' reporting practices into DHIS2 Work with District Biostatisticians and or HMIS Focal persons to conduct joint data quality assessment audits at VSPs to strengthen data capture, reporting and utilization by providers Work with URMCHIP to identify suitable VSPs for RBF training during regional RBF roll-out Facilitate private sector participation in district and national dialogues on service delivery and HSS Build capacity of providers to implement Community Based Health Insurance Scheme(CBHIS) as a financing sustainability plan; identify and work with a suitable partner with strong expertise in building private providers'

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Activity Description Q1 Q2 Q3 Q4 IR Uganda Voucher Plus Activity Work Plan Year 4, submitted August 31, 2018 O N D J F M A M J J A S capacity in CBHIS in Uganda to train and mentor at least 50 VSPs on CBHIS

Build DHTs knowledge and capacity in output based aid mechanisms Strengthen DHMTs' understanding of RBF mechanisms through active participation in facility assessments, accreditation, monitoring of quality, reviewing provider claims during the claims reconciliation processes, and clinical audits for private facilities within their districts Work with RHITES IPs in Eastern and northern regions to strengthen the capacities of districts and contracted providers to conduct maternal and IR2 perinatal death surveillance and Response(MPDSR) Share Activity performance progress reports with Districts to update them but also show the Activity's contribution towards the district's general health metrics Conduct annual Activity performance review meetings for district stakeholders to share progress, learnings, emerging issues and identify areas of synergy Promote and leverage community-based solutions to stimulate saving for health to improve response to RMNCH Collaborate with CDOs, Local governments and other IPs like Batwana World Education, map and identify village loan and savings schemes in the Eastern and Northern regions to link voucher clients to. Conduct community dialogues on health issues in IR2 all identified and functional VSLAs Sensitize and work with VSLAs and/or other savings groups to adopt a health savings component Work with VCBDs to link voucher mothers/families to VSLA and other community- based organizations to promote saving for health SIR 2.2: Evidence, data, and assistance to help develop sustainable financing schemes of MNCH and FP provided Implement Learning Agenda and disseminate findings Disseminate successes, innovations, learnings, and challenges through various channels including the IR2 Budget Sector technical working group, RBF Implementing Team, district stakeholder meetings, annual activity review meeting, annual assembly of RMNCH partners, and MCH technical working group, and periodic stakeholder newsletters

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9.2 Special Reporting Requirements

This annex presents programmatic indicators on maternal and child health (MCH), as well as FP and reproductive health. We use the submission date of the voucher claim, rather than the treatment date. List of Tables Table A1: Y4 Voucher Sales Against Targets Table A2: Voucher Redemption by Type of Service Table A3: Safe Deliveries by Type Table A4: Delivery Outcomes for Y4 Q1 Table A5: Contribution of Voucher Plus Deliveries to District Statistics for Y4 Table A6: Y4 Q1 PNC Attendance vs. Deliveries Table A7: Neonatal Conditions Managed During the Quarter Table A8: Y4 Q1 PPFP Attendances and Deliveries Table A9: Y4 Q1 PPFP Use by Method List of Figures Figure A1: Cumulative Facility Deliveries Against EOP Targets Figure A2: Relationship Between ANC Service and Safe Deliveries Figure A3: Y4 Q1 PNC Clients by Type of Visits Health

A. MATERNAL AND CHILD HEALTH The Activity works to improve the accessibility and quality of basic interventions that can and have saved millions of lives, focusing on five key areas. Maternal health, including ANC, care during and around delivery, and postnatal care As reflected in Table A1, the Activity distributed 29,217 vouchers during the reporting period, achieving 95 percent of the quarterly target and 24 percent of the Y4 annual target. Cumulative voucher sales from the Activity inception now stand at 263,314 vouchers, representing 73.1 percent of the end-of-project target of 360,000. Although there was a slight dip in voucher sales this quarter compared to last quarter— mainly due to the departure of two SBCC Officers and the delayed reimbursements to VSPs—the Activity has remained on course to achieving its end-of-project voucher sales target by the end of Y4.

Table A1: Y4 Voucher Sales Against Targets

Y4 Q1 Cumulative Quarterly voucher sales 29,217 263,314 Quarterly sales target 30,766 360,000

Percent 95% 73.1%

Table A2: Voucher Redemption by Type of Service Y4 Q1% Service Y4 Q1 Client Cumulative Y4 Redemption Redemption Type Visits Client Visits Target Target Achieved ANC1 21,421 158,924 95% 73.3% ANC2 20,824 127,404 60% 71.3% ANC3 18,402 97,923 60% 63%

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Y4 Q1% Service Y4 Q1 Client Cumulative Y4 Redemption Redemption Type Visits Client Visits Target Target Achieved ANC4 11,768 57,983 50% 40% Delivery 21,659 118,408 70% 74.1% PNC 13,009 59,625 50% 60% PPFP 2,548 17,012 45% 17%

The Activity achieved ANC2, ANC3, delivery, and PNC redemption targets. The underachievement for ANC1 reflected the December holidays, when historical trends show that some clients’ routine visits to facilities generally decline. As in past quarters, ANC4 attendance remained below target, mainly because most clients get vouchers after the first trimester. Also, based on good obstetric practice, it is not feasible to have clients who purchase vouchers within a quarter go to facilities for four routine ANCs within the same quarter. Hence, it is best to gauge key service utilization on a voucher Activity like ANC4 on annual as opposed to quarterly basis. The FP target has remained very ambitious given the deep-rooted, social-cultural beliefs and myths surrounding FP services in the two regions of operation. In Q2, the Activity will reorient VCBDs on FP messaging to equip them with skills to help in addressing some of the community myths on FP use.

Figure A1: Cumulative Facility Deliveries Against EOP Targets

Figure A1 indicates that the Activity’s quarterly delivery performance represents 135 percent achievement of quarter’s target and 34 percent of the annual target. The overachievement is due in part to the fact that as the Activity has matured, more women are aware of the importance of delivering at facilities. Another

USAID|Uganda Voucher Plus Activity 26

factor is that data reported are from providers’ claim forms, some of which are late submissions from last quarter. This quarterly target is lower than the previous quarter as it excludes delivery backlogs which were redistributed over Year 5, when the Activity will cease sales and shift focus to redemption. Table A3: Safe Deliveries by Type Delivery Type Y4 Q1 Cumulative to Date C-section 1,426 8,831 Assisted 1,523 15,734 Normal 12,203 87,336 Total 15,152 111,901

Table A3 shows that most clients deliver normally, as desired (accounting for 80 percent of deliveries), while cesarean sections stood at about 9 percent, which is within the MOH acceptable range of not more than 10–15 percent of all deliveries. The values in this table reflect electronic data from the VMIS, but not manually-counted data, as the latter did not disaggregate by delivery type. This explains the discrepancy between the number of deliveries in Table A3 and A4.

Table A4: Delivery Outcomes for Y4 Q1 Delivery Outcome Y4 Q1 Cumulative to Date Outcome Measures Deliveries 21,659 118,408 Live births 21,545 117,736 Stillbirths 112 670 FSBR3 = 6.0 Maternal deaths 6 68 MMR4 = 58

During the quarter, the Activity recorded six maternal deaths, a reduction from the 13 maternal deaths reported last quarter. The main cause of the maternal deaths remains postpartum bleeding either during referral or shortly after arrival at the referral facility. All of these deaths were reviewed by VSPs, and reported to DHOs through the HMIS. Cumulatively, the Activity has recorded 68 maternal deaths since inception. Although the current Activity MMR of 58 is much better than the national average of 336/100,000 (Uganda Demographic and Health Survey [UDHS], 2016), the Activity continues to support the Districts, RHITES partners, and other IPs in areas of operation to avert all deaths. Next quarter, the Activity will strengthen the CEMONC-BEmONC review meetings to address recurring facility-level issues that contribute to these deaths.

Table A5: Contribution of Voucher Plus Deliveries to District Statistics for Y4 Percentage Contribution Total District Deliveries Paid for Period of Voucher Deliveries to Deliveries* by Voucher Plus District Totals Oct–Dec 2018 45,090 21,659 32% *Total district deliveries = Total deliveries registered across the 35 districts implementing this Activity. Source: DHIS2 as of January 21, 2019.

The Activity has continued to make a steady contribution to district deliveries. This quarter, the contribution accounted for 32 percent of all facility deliveries in districts supported by the Activity. The

3 Facility Still Birth Rate: Number of stillbirths in voucher-supported facilities per 1,000 births 4 Maternal Mortality Ratio: Number of maternal deaths per 100,000 live births

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Activity used collated and aggregated data on deliveries from the DHIS2 for all of the 35 supported districts combined, to better understand its contribution. Figure A2: Relationship Between ANC Service and Safe Deliveries

Figure A2 indicates that women who attended three or more ANC visits (i.e., ANC3 and ANC4) were more likely to deliver at a voucher-supported health facility than those who attended only ANC1 or ANC2. This analysis is consistent with data from the previous quarters that have shown similar results. Identification of mothers late in pregnancy is still a challenge to ensuring full utilization of the voucher- covered services. Please note that this figure does not include manually-counted data.

Table A6: Y4 Q1 PNC Attendance vs. Deliveries Y4 Q1 Q1 Cumulative Deliveries 21,659 118,408

PNC clients 13,009 59,625 Percent 60% 50.3%

Table A6 shows that the Activity exceeded its quarterly PNC attendance target of 45 percent and is on course to maintain its end-of-project target of 50 percent. There has been a general improvement of PNC attendance over the quarters due to improved client follow-ups and service integration at some VSPs to limit lost opportunities when clients come for immunization.

Figure A3: Y4 Q1 PNC Clients by Type of Visits

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As reflected in Figure A3, although there has been a slight increase in the proportion of clients getting PNC services at six weeks, from 21 percent last quarter to 24 percent this quarter, most clients (76 percent) who use PNC still come at six days rather than at six weeks. Postnatal care visits at six weeks remain a challenge for the Activity. Mobility challenges and the Activity’s inability to capture PNC data for voucher mothers who access immunization and PNC services at outreach sites and public health facilities all affect our PNC at six weeks performance.

Table A7: Neonatal Conditions Managed During the Quarter

Condition Cases Managed Percent

Neonatal sepsis 83 36%

Acute RTI 100 43% Abdominal colic pain 15 6.5% Pneumonia 12 5% Birth asphyxia 0 0% Prematurity 0 0% Opthalmia neonatum 13 6% Low birth weight 0 0% Other 8 3.5%

This quarter, the Activity received less than half as many neonatal cases as last quarter (only 231, compared to the 502 seen last quarter). This may be due to the delayed reimbursement of VSPs’ neonatal claims, caused by the delay in installing the neonatal interphase in the VMIS to enable claims processing. This has been activated and will be implemented in the next quarter.

B. FAMILY PLANNING AND REPRODUCTIVE HEALTH (Family Health)

Table A8: Y4 Q1 PPFP Attendances and Deliveries Q1 Cumulative

Deliveries 15,152 118,408 PPFP 2,548 17,012 Percent 17% 14.4%

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Table A9: Y4 Q1 PPFP Use by Method No. of Users – Cumulative No. of FP Method Y4 Q1 % Cumulative % Y4 Q1 Users Female condoms 8 0.3% 122 0.7% Contraceptive pills 8 0.3% 123 0.7% Tubal ligation 55 2.3% 533 3.2% Male condoms 50 2.1% 600 3.6% IUCD 105 4.5% 651 3.9% Moon beads 214 9% 1,031 6.1% Injectable 444 19% 3,529 21% Implants 810 34.5% 3,874 23% LAM 656 28% 6,351 37.8% Total 2,350 100% 16,814 100%

Family planning use has generally remained low despite the Activity’s efforts. This is primarily because of strongly held social cultural and religious beliefs in the two regions. The high number of Catholic-based facilities (30 percent of project facilities) explains the popularity of lactation amenorrhea as a means of birth control among voucher mothers. Please note that Table A9 does not include manually-counted data, as they were not disaggregated by FP method. The Activity will continue working with all the key stakeholders to address the social determinants limiting FP use.

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9.3 Success Stories

Program Element: Health Key Issues: Ending Preventable Maternal and Child Death Operating Unit: USAID/Uganda

Religious Leaders Support Increased Access to Voucher-supported Services

Body Copy: Pastor Ewou Michael became an ardent proponent of the Voucher Plus Activity after being invited to meet with Activity staff to learn more about the project. Serving a very rural and traditional community in Soroti district, the pastor initially heard negative rumors and misinformation regarding the Activity from members of his congregation. He remained skeptical of the program until he met Voucher Plus staff members at the Obule Community Health Center. During this meeting, Pastor Ewou learned about the importance of skilled care during pregnancy and delivery, the major barriers to accessing these services in his community, and how the Activity works with communities and providers to bridge this gap in access. “This is when I understood that all the stories in the community were not true. From then on, I started spreading the news about vouchers in my community and church,” reflects Pastor Ewou. Following his meeting at the Obule Health Pastor Ewou Michael of Abango Pentecostal Assemblies of God Church in Center, Pastor Ewou promoted the use of Soroti district vouchers within his family. He personally escorted three of his daughters-in-law to the nearest voucher service provider to receive care using vouchers. He also worked within the voucher network of providers and voucher community-based distributors to organize a sensitization meeting for his community, and to recruit a VCBD to regularly visit the village to follow up with voucher clients and enroll new mothers. Quote: “When I heard it from the pastor…I knew that this project had come to help. That is when I went to the facility for antenatal care with the voucher,” said a community member and new voucher client in Pastor Ewou’s community. Background Information: This story is about collaboration with a local religious leader to increase demand for and reach of voucher services in Soroti district, Uganda. The story occurred under the Health Category.

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Contact Information: Christine Namayanja, Chief of Party, ([email protected]; +256 312506900) Reinvesting Voucher Revenue to Improve Quality Body Copy: Aloi Mission Health Centre III is the

only health facility in a 20-mile radius in Alebtong district, making it the primary source of health care for surrounding communities. When the facility was first assessed by the Voucher Plus Activity, it faced many quality-of- care gaps, including dilapidated infrastructure, no proper waste disposal mechanisms, no ventilation system for the placenta pit, no incinerator, and no refrigerator for proper storage of essential vaccines, medications, or laboratory reagents. The Activity collaborated with the Alebtong District Health Office to help improve the facility so that it could become a voucher service provider and serve this area. As the quality of care improved, service utilization also increased significantly. Facility deliveries Renovation of ceiling boards at Aloi Mission Health increased from a monthly average of 25 to 50, Centre III monthly antenatal care visits increased from an average of 120 to 160, and monthly postnatal care visits increased from an average of 50 to 100. The facility invested revenue from voucher services into additional facility improvements, including upgrades to patient beds and tools to help staff better maintain the compound grounds. Quote: “The compound of the facility is now tidy, thanks to the newly purchased mowing machine. It was previously terrible seeing our compound bushy, yet we had limited capacity to maintain it. Our clients are also happy about the facility now.” – Aloi Mission Health Centre III In-Charge, Sr. Jacinta Abalo Background Information: This story is about improving quality of care at a private health facility in Alebtong district, Uganda. The story occurred under the Health Category. Contact Information: Christine Namayanja, Chief of Party, ([email protected]; +256 312506900)

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Activity Helps Kapchorwa District Improve National Health Ranking from 88 to 35 Body Copy: Each year, the Uganda Ministry of Health releases its annual Health Sector Performance Report, in which district performance on key health indicators is ranked. The 2016/2017 report ranked Kapchorwa district 88th out of 122 districts. This poor performance was largely due to poor maternal and child health outcomes. Since the 2016/2017 Kapchorwa Assistant District Health Officer (MCH) and Kapchorwa District Hospital report was released, the administration Voucher Plus Activity has begun operation in four private facilities in the district. After roughly a year of implementation, the Activity was able to help the district realize significant improvement in four indicators assessed by the Health Sector Performance Report: antenatal care utilization, facility-based deliveries, intermittent preventive treatment, maternal and perinatal death surveillance and response, and health management information system reporting. One of the most drastic achievements was an 11 percent increase in institutional delivery rates, rising from 54 percent (where it had stagnated for the previous three years) to 65 percent. The overall impact of these improvements across indicators moved Kapchorwa from 88th to 35th place out of 122 districts in the 2017/2018 Health Sector Performance Report5. The District Health Officer, Dr. Mwanga Michael, highlights the Activity’s joint supervision and mentorship activities as keys to the improved quality of services and the resulting increased utilization. Quote: “This achievement is mainly attributed to the great contribution made by Voucher Plus. We promise to support the project activities to ensure sustainability of their work. We shall work harder towards position one as a district. Why not?” - Dr. Mwanga Michael, the District Health Officer Background Information: This story is about improving district performance in RMNCH services in Kapchorwa district, Uganda. The story occurred under the Health Category. Contact Information: Christine Namayanja, Chief of Party, ([email protected]; +256 312506900)

5 Annual Health Sector Performance Report, 2017/2018

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9.4 Stakeholder Engagement to Foster Collaboration, Coordination, and Adaptive Management

Central Level Stakeholder Engagements Stakeholder Main contacts Objectives Dr. Dinah Busiku Nakiganda  Actively participated in two MOH MCH Assist Commissioner Cluster/Technical Working Group meetings in Oct. Reproductive Health and Dec. 2018 to ensure the contribution of the private sector is visible and the learnings are disseminated. Ministry of Health  Attended the 2nd National Annual RMNCH Assembly at Imperial Royale. Dr. Sarah Byakika  Participated in two RBF implementing partners Commissioner Planning meetings.  Finalized the framework for URMCHIP and Voucher Plus coexistence. USAID/SITES Dr. Daraus Bukenya  Participated in two USAID IPs’ quarterly review Chief of Party meeting at SITES, which included a review of newborn programming and malaria partner performance review. USAID ASSIST Karamagi Esther  Sharing of best practices learned by ASSIST with Chief of Party field-based Activity staff.  Learning shared on quality improvement project implementation by facilities and change package developed. Save for Health Fred Makaire  Partnered with Save for Health Uganda to organize Executive Director the 3rd National Community Health Financing Conference, November 8-9, 2018, to promote the role of voucher schemes in UHC and identify opportunities for partnership and learning to foster health saving behaviors and practices among voucher communities.  Facilitated the attendance of 17 VSPs at the 3rd National Community Health Insurance Conference in November 2018 to build local capacity to implement health financing mechanisms for sustainability. Communication for Sheila Coutino  Access to CHC family planning materials for Health Communities Chief of Party adoption by the Activity. (CHC) Uganda Healthcare Improving Internal Quality  Rollout of the SQIS tool developed by UHF to 124 Federation (UHF) Assurance facilities, reaching 538 health workers to date. The tools are to be entered into the online system by UHF.

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District Stakeholder Engagements Stakeholder Objective Comments Decide End Link vulnerable teenage mothers to  The SBCC officer (SBCCO) shared information Child Marriage voucher services (education on SRH about Voucher Plus to the project team and project (Apac & and safe motherhood services) champions of change facilitators. Three of the Kole districts) facilitators are VCBDs.

RHITES-East  Promoting synergy in areas of  Together with RHITES-E, the Activity engaged common interest obstetricians from Soroti regional referral RHITES-Lango  Quality improvement in MNCH hospital, the RDC Katakwi, Vice Chairman LC V RHITES- Acholi services and MPDSR guidelines’ Katakwi, DISO Katakwi, heads of district rollout departments, District Health Team members, and  Fostering effective EMTCT Katakwi Hospital staff in MPDSR meeting held in linkages Katakwi. Also engaged RHITES-E district program  Participation in stakeholder officer in MPDSR meetings in Soroti. meetings organized by either  Participated in RHITES-funded district partner performance review and Partner coordination  Improving documentation of meetings in Serere, Bukedea, Soroti, Kumi SGBV at facilities in the district  Engaged the RHITE-E malaria technical officer in  Capacity strengthening for VSP mentorship of staff at Sipi Gamatui HC II and staff Kaserem Christian HC III on new malaria guidelines and mentored them on accurate completion of HMIS tools. RHITES N-Lango trained staff from two voucher covered districts in management of malaria (Amuda HC II and Adwoki Maternity Home).  RHITES-E and RHITES-Acholi teams facilitated distribution of mosquito nets to at least 25 voucher facilities through the President’s Malaria Initiative with support from USAID. Distribution made through JMS.  RHITES N-Lango provided landline phones to at least five voucher facilities to improve communication for follow-up of HIV positive clients. PSI Improving FP service delivery  Kabasa Memorial HC was supported with FP products by PSI.

TASO Gulu Improving EMTCT service delivery  TASO Gulu supported the district health team to through linkages assess EMTCT service provision at seven facilities in Gulu. TASO Improving EMTCT services through  Linked two voucher facilities in Bulambuli district public-private sector linkages the Eastern region to public facilities for EMTCT during the quarter. Uganda Improving service delivery at facilities  Olimai CBO HC and Mukongoro Community Reproductive Health Services in Kumi and Kolonyi Hospital in Maternal Child Mbale participated in the RBF training of trainers Health Services in their respective districts. Improvement Project

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Stakeholder Objective Comments

District local Foster inclusive stakeholder  Strengthened referral and service linkages for gov’ts and the engagement and local-led solutions ART, FP commodities, and immunization. District Health to HSS challenges to achieve  HMIS supportive supervision to VSPs by District Team sustained collaboration and impact biostatisticians and/or HMIS focal persons in 35 beyond Voucher Plus Activity districts. implementation period  Engaged DHOs and biostatisticians, resulting in Support to the Activity’s SBCC inclusion and activation of eight voucher facilities activities into DHIS2 in six districts.  13 district health team members participated in supportive supervision, mentorship, and SQIS rollout for 22 VSPs.  Conducted 36 visits to 21 DHOs to provide briefings on Voucher Plus implementation progress.  17 VSPs participated in district performance review meetings.  Mbale SDA received FP commodities.  Mbale made Rehema MC a satellite site for EMTCT to improve ART services and documentation and reporting for EMTCT in the district.  Participated in the Extended District Health Team meeting in Mbale and a budget conference in Mbale.  Spearheaded a key stakeholder meeting in Acholi sub-region to identify local solutions to maternal and newborn outcomes arising from poor referral practices. Four public facilities and 24 VSPs from the region participated in this meeting held at St. Mary's, Lacor Hospital, Gulu.  Presented about the Activity to district leadership and district health teams at the Aber Hospital Annual General Assembly, two hospital management committee meetings for Pallisa General Hospital, Butiru Chrisco Hospital, and the launch of CEMONC services at Divine MC (also attended by the RDC Sironko). Public Sector Improvement of quality of care,  Secured daily activity laboratory registers from facilities referral system, and HMIS Gulu Regional Referral Hospital for VSPs in Gulu.

Profile of district leaders who participated in the Activity’s programs in Q1 District Leaders Sub-county Leaders Integrated SBCC and Marketing Campaigns Resident district commissioners, district chairmen, chief Local Council 3 chairpersons, Local Council 2 administrative officers, district health officers, assistant chairpersons, Local Council 1 chairpersons, sub- district health officers MNCH, district health educators, county chief, health assistants, parish chiefs, town health sub-district in-charges, district secretaries for agents, community development officers, social/health services at LV councils councilors, religious leaders, cultural leaders, Village Health Team members

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9.5 Activity Learnings and Adaptions in Past Periods

Learning Adaption Period Results Private providers Clinical validation exercise. Y2, Q1 Terminated 25 providers who did cheated the mapping not meet the required basic quality Mapping and accreditation study. Y2, Q3 and accreditation standards. system to be accredited Lessons from the study Y3, Q2 Suspended 36 providers, who into the voucher implemented in future provider and Q3 were required to make scheme. mapping and accreditation exercises. improvements to participate in the voucher scheme. To date, 25 previously suspended providers have made improvements and rejoined the voucher scheme. Majority (108) of the In collaboration with MOH/ACP and Y2 Q2 Twenty-eight providers were selected VSPs were not DHOs/district HIV focal persons, accredited to provide ART. These accredited by MOH to assessed 108 non-ART VSP sites. have been linked to the central offer ART services. supply chain mechanism (Joint Medical Stores and/or MAUL) for ART stocks. Eighty non-ART VSPs have been linked to nearby public or private ART-accredited facilities as outreach sites. High staff turnover at On-site mentorships where the full Since Y2, Reduced interruptions in service facilities continues to facility team is engaged in training ongoing delivery as VSPs operate full-time. affect quality of care and are helping to bridge some gaps waste the effort and created when one trained staff resources used to train moves on. and provide mentorship. Planned a business skills training for providers intended to build capacity of providers business skills, with an emphasis on financial management and staff motivation and retention. Inadequate ambulance Collaboration with and engagement Since Y2, Made district ambulances made services, including long of DHOs to support referral ongoing available to VSP facilities in 33 distances between mechanisms. districts. referral sites. Encouraged private providers to Since Y2, Provider investments in ambulance invest in transport for emergency ongoing services. Five providers have referrals. bought vehicles that are used for referral. Enrolled private wings of public facilities to reduce distance. Enrolled four private wings of public sector to reduce referral distances. Service delivery Activity reorganized the service Y2 Q3 Dedicated supervision and component of the delivery component to ensure management of the VSP service Activity is central to effective and efficient management package. quality service provision and operations. Abt Associates and requires direct expanded its technical team to control by the prime include seven new field-based clinical (Abt Associates). staff, who manage quality assurance and build capacity of providers.

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Learning Adaption Period Results Number of VCBDs per Increased the number of VCBDs per Y3 Q1 to This adaption, combined with the facility (two) was too facility from two to an average of Q3 purchase of vouchers by VSPs, low to make impactful four per facility. Some facilities were resulted in voucher sales growth increase in voucher allowed to have more than four by 61 percent in Q2 (against Q1), sales and redemption. based on the geographical coverage and by 36 percent in Q3. The two VCBDs were of their facilities and population not adequately covering distribution around their facilities. the defined radius of 5km around the facility. Limited services for Expanded newborn package to Y3 Q2 Over the past two quarters, newborn care and cover neonatal infections acquired managed 421 sick newborns. exclusion of sexually within the first 28 days of life as transmitted infections opposed to only immediately after services for spouses of birth. The voucher covers routine pregnant women general examination after birth, and affected demand and postnatal check-ups at six days and uptake of voucher at six weeks, and whenever mother service package, reports any danger signs. Strong influence of The Activity enrolled TBAs as Y3 Q2 To date, 270 mothers have traditional birth voucher distributors and promoters. accessed voucher through TBAs, attendants (TBAs) – To date, the Activity works with 13 of whom 173 have already used at mothers still go to TBAs TBAs attached to 10 facilities. least one MNCH service. for delivery despite availability of subsidized voucher services. The expanded network Introduction of the Peer VCBD Y3 Q2 This approach has enabled of VCBDs, from 320 in approach in Peer Support Model to dedicated, frequent and active Y2 to 640 VCBDs, manage the expanded network. support to VCBDs, keeping track required dedicated of performance, and facilitating supervision and follow- rapid response to challenges. The up to ensure an effective Activity scaled up this innovative demand creation and approach to all the voucher distribution system. districts in Q3. Lack of funds for Adjustments in the distribution Y3 Q2 This new adaption resulted in VCBDs to buy vouchers mechanism to allow providers to increased sales, from an average slowed sales and buy vouchers for the VCBDs as an of 10,000 vouchers per month to pregnant women’s incentive to ensure constant 20,000 vouchers a month. access to vouchers. availability of vouchers in the Voucher sales have increased Client follow-ups to market, and subsequently increase significantly, from 23,621 in Q1 to ensure use of vouchers sales. 46,720 in Q3. also dipped, as VCBDs The Activity has also seen lacked funds and improved motivation of VBCDs, motivations to travel to resulting in vigilant follow-up of client homes. mothers and improved voucher redemption.

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Learning Adaption Period Results Poor use of data form Using mobile data collection tools to Y3 Q4 Information is in real time and Community engagement enhance monitoring for efficiency facilitates productive, evidence- activities as identified by (real-time, cost-effective and more based discussions. SBCCOs and Peer accurate). SBCCOs. The use of The tools were designed using an manual/paper data ODK platform hosted online by collection tools has not Kobotoolbox.org. The VCBDs and been very effective for SBCCOs can enter the data offline learning, as this always using an application (Kobocollect), delays data entry and then submit to the Cloud analysis of information. (Kobotoolbox.org) when connected to the internet. Provider Recruitment of interns/temporary Y3 Q4 Recruitment of interns as reimbursements have a staff for claims processing. We used temporary staff to clear the dramatic effect on this approach whenever there is a backlog of claims helps to get the quality of care. surge in the volume of claims. VMA back on a timely reimbursement cycle. Persistent challenges in Stakeholder forums to discuss and Y4 Q1 Improvement in referrals as referrals resulting in identify local solutions to improve referring facilities (including public preventable maternal maternal and new-born outcomes. facilities) received feedback on deaths. where they need to act; improved relations between referring and referral facilities; and a reduction in maternal deaths reported at St. Mary’s Lacor Hospital. Increase in SBCC and Introduction of a new mHealth Y4 Q1 All adaptions to be completed in service delivery solution to improve processes for Y4Q2). activities increased real-time data capture from VSPs volume of data that and VCBDs. required corresponding increase in VMA Recruitment of more claims capacity. processing staff. Procurement of new hardware to support the enhance performance of the VMIS (to be competed in Y4Q2).

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9.6 Updated Learning Agenda Schedule

Project Data Collection Learning Topic Research Question(s) Source Approach Status Year (how, by who) 3 Private Provider Mapping What are the lessons learned in AMELP Learning Qual. KIIs, project staff Completed and Accreditation After- using mapping and accrediting for Agenda Question & Action-Review; Long selective contracting of VSPs? IR2 SOW Report 3 Private Provider Mapping What are the lessons learned in AMELP Learning Qual. KIIs, project staff Completed and Accreditation After- using mapping and accrediting for Agenda Question & Action-Review; K&L brief selective contracting of VSPs? IR2 SOW

3 Voucher Non-redemption What are the reasons behind Operations research Qual. KIIs, consultant Completed Study voucher holders not redeeming for requested by AOR and any services? IR 2 SOW 3 Client Satisfaction What can we learn about client AMELP Learning Quant. Client survey (399 Internal review satisfaction with the voucher Agenda Question and clients), consultant mechanism? Including the IR 2 SOW perception of the quality of services and willingness to pay for services/voucher. 3 Effectiveness of the Poverty Was the Poverty Grading Tool AMELP Learning Qual. & KIIs with VCBDs, Internal review Grading Tool (PGT) in effective in targeting beneficiaries of Agenda Question and Quant. FGD with SBCCOs Reaching Beneficiaries the safe motherhood voucher? IR 2 SOW and managers, and quant. Data from client satisfaction survey 3 Effectiveness of Demand- What are the lessons learned in AMELP Learning Qual. KIIs with VCBDs, Final generation Activities in increasing beneficiary demand for Agenda Question and FGD with SBCCOs review/production Increasing Voucher the service package? IR 2 SOW and SBCC Redemption managers YEAR 4 4 PPFP Non-utilization What are the programmatic Programmatic analysis TBD TBD TBD among Voucher Clients enablers and barriers to Voucher requested by AOR clients using PPFP?

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Project Data Collection Learning Topic Research Question(s) Source Approach Status Year (how, by who) 4 Purchasing to Stimulate What is the effect of purchasing IR2 SOW Qual. & Survey with VSPs Study design in Q2 Interest in Participating in mechanism on capacity and Quant. Year 4 Output Based Financing willingness of providers to Mechanisms: Lessons implement Community-Based Learned Health Insurance (CBHI) mechanisms/health cooperatives or other health financing mechanisms?

4 Selective Contracting: What are the key findings from IR2 SOW Qual. Interviews with Study design in Q2 Identifying and mitigating establishing a claims management PwC and BDO and Year 4 fraud and verification system to mitigate their experience on and prevent fraud? this activity and others; 4 Purchasing to Stimulate How is the purchasing mechanism AMELP Learning Qual. & IVEA provider Study design in Q3 Supply Side Improvements: stimulating improvements on the Agenda Question and Quant. survey and also Year 4 Lessons Learned supply side? IR 2 SOW clinical audit; and interviews of VSPs

4 Coexistence and How can supply side and demand AMELP Learning Qual. Document review, Draft document harmonization of multiple side financing mechanisms work in Agenda Question and project staff ready for MOH output based financing harmony to achieve UHC IR 2 SOW review mechanisms objectives? TBD TBD Defining the benefit What are the lessons learned for IR2 SOW Qual. After-Action TBD package and establishing establishing, monitoring, revising Review methods provider reimbursement and continually improving the rates provider reimbursement rates for the service package?

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Project Data Collection Learning Topic Research Question(s) Source Approach Status Year (how, by who) TBD The effectiveness of What are the roles, relationships IR2 SOW Qual. TBD institutional roles, and collaborative mechanisms in responsibilities, communities and government collaboration and linkages structures that are enabling or between the private sector impeding private health system and District Health Officers strengthening? and the private sector and other public facilities and community organizations

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